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Blunt pancreatic injury (BPI) is relatively uncommon in children, and is associated with relatively high morbidity and mortality, especially if diagnosis is delayed. The aim of this report is to review the literature regarding controversial questions in the early diagnosis and management of pediatric BPI. A representative case of blunt pancreatic trauma in a six-year-old girl with delayed diagnosis and intraoperative and postoperative complications was described. A systematic search of databases and the grey literature in Scopus and Web of Science using relevant keywords was conducted. A total of 26 relevant articles published in last 5 years were found in PubMed. Although early CT performance is considered part of initial pancreatic trauma workup, the sensitivity of CT for detecting main pancreatic duct injuries in children is relatively low. MRCP and ERCP (if available) are useful for assessing ductal injury and should be performed when the status of the pancreatic duct is unclear on the CT. Most patients with low-grade pancreatic damage may be treated conservatively. Although surgery involving distal pancreatectomy remains the preferred approach for most children with high-grade pancreatic injury, there is growing evidence to suggest that non-operative management (NOM) is safe and effective. Most pancreatic pseudo cysts following NOM had relatively mild complications, and most resolved spontaneously. For those children who do require surgery, a conservative operative approach with the least risk is advocated. In conclusion, the optimal management for pediatric pancreatic trauma is controversial. Further clinical trials are required to generate clinical practice guidelines on pancreatic trauma in a child population.

Background Chest pain is a common condition in the emergency department (ED). High-sensitivity cardiac troponin (hs-cTn) assays are crucial for diagnosing acute coronary syndrome, but the implications of “negative but measurable” hs-cTn levels are not well understood. This study assesses the outcomes of patients with acute chest pain discharged from the ED based on their hs-cTn levels. Methods This retrospective cohort study analyzed medical records of patients aged 18 and older presenting with chest pain to the Tel Aviv Sourasky Medical Center ED from 2017 to 2022. We compared patients with negative but measurable hs-cTn levels (3–50 ng/L) to those with very low hs-cTn levels (< 3 ng/L). Primary outcomes included 90- days coronary angiogram (CAG), and secondary outcomes were 7- days ED revisits, 14-days hospital admissions, and 30- days mortality. Results Of 32,162 eligible patients, 23,297 had hs-cTn levels ≤ 50 ng/L. Patients with negative but measurable hs-cTn levels had higher rates of 90-days CAG (1.8% vs. 0.5%, p  < 0.001), 7-day ED revisits (5.2% vs. 3.3%, p  < 0.001), 14-day hospital admissions (3.1% vs. 0.9%, p  < 0.001), and 30-day mortality (0.3% vs. 0.01%, p  < 0.001) compared to those with very low hs-cTn levels. Independent predictors for 90 days CAG included age ≥ 57 years, male sex, and hs-cTn ≥ 3.5 ng/L. Conclusions Negative but measurable hs-cTn levels are linked to worse outcomes than very low hs-cTn levels in discharged ED patients. Closer follow-up and further cardiac evaluation may be warranted for these patients.

The maintenance of behavioral change over the long term is essential to achieve public health goals such as combatting obesity and drug use. Previous work by our group has demonstrated a reliable shift in preferences for appetitive foods following a novel non-reinforced training paradigm. In the current studies, we tested whether distributing training trials over two consecutive days would affect preferences immediately after training as well as over time at a one-month follow-up. In four studies, three different designs and an additional pre-registered replication of one sample, we found that spacing of cue-approach training induced a shift in food choice preferences over one month. The spacing and massing schedule employed governed the long-term changes in choice behavior. Applying spacing strategies to training paradigms that target automatic processes could prove a useful tool for the long-term maintenance of health improvement goals with the development of real-world behavioral change paradigms that incorporate distributed practice principles.

Background and importance Heat stroke is a life-threatening condition affecting children worldwide. Rapid cooling remains the most important feature of emergency management. The accepted preferred method of evaporative cooling in the ED as listed by the reference text book endorsed by the Israeli Society of Pediatric Emergency Medicine (PEMI), is actively cooling the patient by spraying him with water and positioning fans to blow air across the body. Objective This study aimed to assess Israeli health care workers (HCWs) medical professionals’ knowledge and preparedness of treating heat stroke and recommend policy changes to ensure better treatment based on survey results. Design, settings and participants A cross-sectional survey of all HCWs working in an ED that accepts children was conducted. An online questionnaire was utilized to assess heat stroke management practices and available resources in all Israeli pediatric emergency departments (PEDs). Main results Data from 208 health care workers was analyzed. Only 30% of the participants reported ever treating a patient with exertional heat stroke. Two scenarios were presented to the participants: motor vehicle-related child hyperthermia (MVRCH) in an infant and an adolescent with exertional heat stroke. One hundred twenty-five (60%) and 83 (40%) participants, respectively, listed cool water with a fan as the primary mode of cooling, which is considered the appropriate preferred method of evaporative cooling in the PED. Certificated pediatric emergency medicine (PEM) physicians answered significantly more correctly regarding both scenarios’ management ( P  < 0.001). Participants who were trained via simulation in the past, answered significantly more correctly regarding the exertional heat stroke scenario ( P  < 0.01), however no difference was found regarding the MVRCH case. Conclusions: The present study exposes weaknesses in HCW knowledge, PED resources, and published PED policies for appropriate management of children following heat stroke. Our finding emphasizes the importance of both certificated PEM physicians attendance and simulation performance for implementing proper management of patients with heat stroke. A policy change should be performed among the Israeli PED community, with respect to establishing and implementing guidelines for treatment of exertional heat stroke. A future study, following an interventional simulation program is planned to be performed.

Introduction: Emergency medicine (EM) was recognized as a specialty in Israel in 1999. Fifty-nine of the 234 (25%) attending physicians working in emergency departments (ED) nationwide in 2002 were board-certified emergency physicians (EP). A 2012 study revealed that 123/270 (45%) of ED attendings were EPs, and that there were 71 EM residents. The EPs primarily worked midweek morning shifts, leaving the EDs mostly staffed by other specialties. Our objective in this study was to re-evaluate the EP workforce in Israeli EDs and their employment status and satisfaction 10 years after the last study, which was conducted in 2012. Methods: We performed a three-part, prospective cross-sectional study: 1) a survey, sent to all EDs in Israel, to assess the numbers, level of training, and specialties of physicians working in EDs; 2) an anonymous questionnaire, sent to EPs in Israel, to assess their demographics, training, employment, and work satisfaction; and 3) interviews of a convenience sample of EPs analyzed by a thematic approach. Results: There were 266 board-certified EPs, 141 (53%) of whom were employed in EDs full-time or part-time. Sixty-two non-EPs also worked in EDs. The EPs were present in the EDs primarily during weekday morning shifts. There were 273 EM residents nationwide. A total of 101 questionnaires were completed and revealed that EPs working part-time in the ED worked fewer hours, received higher salaries, and had more years of experience compared to EPs working full time or not working in the ED. Satisfaction correlated only with working part time. Meaningful work, diversity, and rewarding relationships with patients and colleagues were major positive reasons for working in the ED. Feeling undervalued, carrying a heavy caseload, and having complicated relationships with other hospital departments were reasons against working in the ED. Conclusion: Our study findings showed an increase in the number of trained and in-training EPs, and a decrease in the percentage of board-certified EPs who persevere in the EDs. Emergency medicine in Israel is at a crossroads: more physicians are choosing EM than a decade ago, but retention of board-certified EPs is a major concern, as it is worldwide. We recommend taking measures to maintain trained and experienced EPs working in the ED by allowing part-time ED positions, introducing dedicated academic time, and diversifying EP roles, functioning, and work routine.

Objectives Coronavirus Disease 2019 (COVID-19) is a highly infectious viral pandemic that has claimed the lives of millions. Personal protective equipment (PPE) may reduce the risk of transmission for health care workers (HCWs), especially in the emergency setting. This study aimed to compare the adherence to PPE donning and doffing protocols in the Emergency Department (ED) vs designated COVID-19 wards and score adherence according to the steps in our protocol. Design Prior to managing COVID-19 patients, mandatory PPE training was undertaken for all HCWs. HCWs were observed donning or doffing COVID-19 restricted areas. Setting Donning and doffing was observed in COVID-19 designated Emergency department and compared to COVID-19 positive wards. Participants All HCWs working in the aforementioned wards during the time of observation. Results We observed 107 donning and doffing procedures (30 were observed in the ED). 50% HCWs observed donned PPE correctly and 37% doffed correctly. The ED had a significantly lower mean donning score (ED: 78%, Internal: 95% ICU: 96%, p  < 0.001); and a significantly lower mean doffing score (ED: 72%, Internal: 85% ICU: 91%, p  = 0.02). Conclusions As hypothesized, HCWs assigned to the designated ED wing made more protocol deviations compared with HCWs positive COVID-19 wards. Time management, acuity, lack of personnel, stress and known COVID-19 status may explain the lesser adherence to donning and doffing protocols. Further studies to assess the correlation between protocol deviations in use of PPE and morbidity as well as improvement implementations are required. Resources should be invested to ensure PPE is properly used.

The use of a single C-reactive protein (CRP) value to differentiate between bacterial and non-bacterial causes is limited. Estimated CRP velocity (eCRPv) has shown promise in enhancing such discrimination in adults. This study aims to investigate the association between eCRPv and bacterial etiologies among pediatric patients with very elevated CRP levels. We conducted a retrospective analysis of patients under 18 years of age who had been admitted to our Pediatric Emergency Department from 2018 to 2020 with a fever and CRP levels ≥ 150 mg/L. Bacterial and non-bacterial etiologies were determined from hospital discharge diagnoses, which were monitored independently by three physicians from the research team. The records of 495 suitable patients (51.2% males, median age 3.2 years) were retrieved of whom 444 (89.7%) were eventually diagnosed with bacterial infections. The mean CRP levels were significantly higher for bacterial etiologies compared with other causes (209.2 ± 59.8 mg/L vs. 185.6 ± 35.8 mg/L, respectively, p  < .001), while the mean eCRPv values did not differ significantly ( p  = .15). In a time course analysis, we found that specifically in patients presenting ≥ 72 h after symptom onset, only a eCRPv1 level > 1.08 mg/L/h was an independent predictor of bacterial infection (aOR = 5.5 [95% CI 1.7–17.8], p  = .004).     Conclusion : Pediatric patients with very high CRP levels and fever mostly have bacterial infections. eCRPv levels, unlike CRP values alone, can serve as the sole independent predictor of bacterial infection > 72 h from symptom onset, warranting further prospective investigations into CRP kinetics in pediatric patients. What is Known: • The use of a single C-reactive protein (CRP) value to differentiate between bacterial and non-bacterial causes is limited. • Estimated CRP velocity (eCRPv) has shown promise in enhancing such discrimination in adults, but data on CRP kinetics in pediatric patients is sparse. What is New: • eCRPv levels, unlike CRP values alone, can serve as the sole independent predictor of bacterial infection > 72 h from symptom onset in pediatric patients with remarkably elevated CRP levels.

There are no guidelines for the optimal manner and timing of permanent central catheter removal in the hemodynamically unstable pediatric hemato-oncology patient with suspected catheter-related bloodstream infections (CRBSI). Our goals were to examine current practices of permanent central catheter management and choice of removal in the hemodynamically unstable pediatric patient with suspected CRBSI among practitioners in diverse subspecialties. We performed a literature review on the subject, and conducted a multi-disciplinary survey included pediatric oncologists, pediatric emergency medicine physicians, and pediatric intensive care physicians whom we queried about their choice of permanent central catheter management and removal while treating the hemodynamically unstable pediatric patient with suspected CRBSI. Most of the 78 responders ( n  = 47, 59%) preferred to utilize the existing permanent central catheter for initial intravenous access rather than an alternative access. There were no significant differences between physician subspecialties ( p  = 0.29) or training levels ( p  = 0.14). Significantly more pediatric emergency medicine physicians preferred not to remove the permanent central catheter at any time point compared to the pediatric hemato-oncologists, who preferred to remove it at some point during the acute presentation (44.4% vs. 9.4%, respectively, p  = 0.02). Conclusion : Our study findings reflect the need for uniform guidelines on permanent central catheter use and indications for its removal in the hemodynamically unstable pediatric patient. We suggest that permanent central catheter removal should be urgently considered in a deteriorating patient who failed to be stabilized with medical treatment. What is Known: •  There are no guidelines for the optimal choice and timing of permanent central catheter removal in the hemodynamically unstable pediatric hemato-oncology patient with suspected catheter-related bloodstream infection (CRBSI). What is New: •  We found variations in practices among pediatricians from diverse subspecialties and conflicting data in the literature. •  There is a need for prospective studies to provide uniform guidelines for optimal management of suspected CRBSI in the hemodynamically unstable pediatric patient.

PurposeWe examined the predictability of selected parameters for establishing the need for urgent care following multi-trauma as a means to warrant the highest level of trauma activation and potentially improve over- and under-triage rates.MethodsIn this retrospective cohort study of multi-trauma patients aged ≥ 16 years performed at a level 1 trauma center, trauma activation criteria and additional characteristics were examined with respect to treatment urgency, defined as: a direct disposition to the operating room or intensive care unit, initiating acute intervention in the trauma room, and in-hospital death within 7 days of admission.ResultsWe enrolled 1373 patients (median age 36.0 years). The following parameter were inserted into the final multivariable model: age > 75 years, male sex, Charlson comorbidity index, trauma circumstances and mechanism, signs of respiratory distress, systolic BP ≤ 110 and GCS ≤ 13. Adjusted independent predictors of acute care requirement were as follows: GCS ≤ 13 (aOR 5.27 [95% CI 3.45–8.05], p < 0.001), systolic BP ≤ 110 mmHg (aOR 2.15 [95% CI 1.45–3.21], p < 0 .001), respiratory distress (aOR 2.05 [95% CI 1.53–2.77], p < 0.001), and age ≥ 75 years (aOR 1.90 [95% CI 1.18—3.08], p = 0.008).ConclusionA GCS ≤ 13, systolic BP < 110 mmHg, signs of respiratory distress, and age > 75 years best predicted the need for acute care following multisystem trauma. Prospective studies are warranted to confirm the predictability of these criteria and to assess the extent to which their implementation will refine over- and under-triage rates.

Abstract PurposeTo construct a new pediatric ocular trauma score for predicting visual outcome after open globe injuries (OGI) and to compare it to the ocular trauma score (OTS) and pediatric ocular trauma score (POTS).MethodsThis is a retrospective chart review study. For each case, the following data were collected: demographics, mechanism of the injury, initial ophthalmologic findings, presented and last follow-up visual acuity (VA), ocular treatments, and final ocular findings. We then analyzed the risk factors for the poor visual outcome (VA ≤ 20/200), and a modified pediatric ocular trauma score (MPOTS) was constructed accordingly and compared to the OTS and POTS for predicting poor outcome. Finally, a different cohort of pediatric OGIs was used for score validation.ResultsForty-five cases were included, significant predicting factors for poor visual outcome were initial VA ≤ 20/200, zone 2–3 locations of injury, presence of retinal detachment, vitreous hemorrhage, hyphema, and iris prolapse at initial presentation. The calculated Spearman correlation coefficients between each system score and poor visual outcome were OTS 0.56, POTS 0.57, and MPOTS 0.64 (P < 0.001 for all). A total of 71 new cases were used as validation cohort, and calculated Spearman correlation coefficients between each system score and poor visual outcome were: OTS 0.50, POTS 0.51, and MPOTS 0.53 (P < 0.001 for all).ConclusionsWe suggest a new scoring system for predicting poor final visual outcomes after OGI’s in children, which is simpler and more clinically suitable for this study population. It was found to be a better predictor of visual outcome in this scenario compared with existing scoring systems.